Gulu, Uganda, February 2015
Tony Walter Onena is a retired registered nurse from Gulu, Uganda and probably the only health worker to have beat Ebola 6 times: 5 times in Uganda in 2000, 2007, three outbreaks in 2012 and now he beat it in Monrovia, Liberia. Tony is a strong personality, he doesn’t fear anything: Ebola, jealous colleagues, hospital directors, international researchers or presidents who want to direct him against best Ebola care practices.

Gulu outbreak 2000

When Ebola struck Gulu in Uganda in 2000 Tony didn’t know at first what it was until he attended a funeral in a village where people talked about a disease that would strike you and that meant you would die. When he returned to Gulu the medical director of Gulu Referral Hospital Dr. Felix Kaducu requested nurses and doctors to come and work in the Ebola isolation ward. Nobody volunteered – except Tony Walter and a handful of staff. After him, volunteers slowly reported in when WHO and the Ministry of Health organized special payments.

One of the first specially trained WHO experts that came to Gulu, Dr. Simon Mardel, immediately caught Tony’s full attention because his practical and simple training methods made sense in Gulu. Tony secretly recorded every training the WHO expert held and he learned all the procedures by heart. The expert was particularly keen on strictly sticking to simple routines and Tony more than once saw how the expert would loudly and promptly criticize anybody who was sloppy, lazy or careless in handling infective patient material, blood or linen. In the beginning they only had simple gloves and their plain clothes but the expert brought in the idea of triple gloves, protective suits and basic protective routines handling patients.

Follow the money

Tony was worried about the payment issue, an issue that would come up again and again, also in Liberia. The introduction of a special payment for Ebola work tended to attract a type of health workers that were charmed by the extra allowance more than they were dedicated to being careful health professionals working in a hazardous environment.

Tony remembers how their sloppiness put everybody at a risk: needles left in patients beds, blood drops left on clothes or unidentified clothes, linen and drip lines left on the floor. It also attracted people that liked to give orders and get a high pay for it and that taught Tony two things: separate management from the clinical team, management should take place outside the clinical setting. You train the team, go through the routines until everybody is fearless, safe and confident and then you work as a uniform team that does not jeopardize each other’s safety. Many managers tried to interfere and take advantage of Tony’s team but he learned to separate clinical care of Ebola patients from management issues. That, he says, gained him a lot of enemies, but his teams have always beat Ebola and none of the team members contracted Ebola.

Monrovia, Liberia, August 2014

Tony was asked by the Ugandan government, with his Gulu team and colleagues from other parts of Uganda, to help combat Ebola in Liberia. When they arrived in Monrovia, they were assigned to a very big hospital that had been shut down by MSF three weeks before because so many health workers had died from Ebola. There was space for 30 Ebola patients but shortly after the Ugandan team had arrived the rumor must have spread as he said: “They came with three ambulances the first day with 12-15 patients in each and by the end of the day we suddenly had 70 patients in 30 beds”.

As in Gulu the Ebola extra pay had attracted types of health workers that were not dedicated to combatting Ebola but merely for the money. That turned out to become a factor that significantly delayed the Ebola response in Monrovia. Health workers hadn’t been paid their salaries for three months but they knew funding was coming in to the government. The Liberian health workers went on strike and invited then president of Liberia to come and dress in the Ebola protection outfit and go the wards to get a feeling of how stressful the job was.

“At one point”, Tony recalls, “I was very worried, because our Liberian colleagues were so frustrated over the lacking salaries, that they threatened to wrap up one of the Ebola victims, carry the corpse to the Ministry of Health and dump it there to demonstrate their anger”. They were stopped but only last minute. Tony explains: “People of Monrovia don’t have gardens to dig, they don’t have their own food, so they have to buy food, and that requires a salary”. Tony is certain that the salary issue seriously delayed the Ebola response and should have been dealt with months before.

Fatal private clinics

An even more worrying, and ignored, consequence of the lacking salary to health workers was that health workers in frustration started to operate small private Ebola treatment clinics at home or in town to earn some money to survive. After a short 1 day training they started handling Ebola patients in their homes with very little, if any, clinical experience, no protective equipment, no lab facilities (meaning patients without Ebola were treated together with Ebola patients) and no isolation facilities or routines. Tony’s gaze becomes distant explaining this, he is almost counting the huge number of cases that must have followed from this disorganized and dangerous practice hidden from authorities and the media.

Tony acknowledges that health workers did it to survive but it contributed to the epidemic and as Tony remarks “Many of these nurses ended up dying from Ebola themselves in their own clinics because they lacked skills and equipment and their training was simply not up to date”. Tony says that one of the experiences he gained during the Uganda outbreaks was that training is about seeing and doing in practice but most training is too theoretical: “you should learn by doing, not just by listening”.

Forced to focus on treatment

Another factor that Tony keeps mentioning is that practically all health facilities and workers were employed with Ebola management. But patients of course kept coming with other acute health problems as diarrhea, malaria, tuberculosis, AIDS or NCDs. These patients were treated as Ebola patients but initially didn’t suffer from it – they contracted it in hospital.

The weak health care system in Liberia forced donors and international aid organisations to focus on treatment and management of cases, while the most important activity: public messages, were given less priority. That was a huge mistake but what else could they do under the circumstances?

Ugandans are good listeners

Comparing the Uganda Ebola response to the present situation in West Africa, Tony has a lot to say. “For one thing, Ugandans are good listeners. If we tell them: don’t shake hands and don’t sit too close in church, they will follow the message. That wasn’t the case in Liberia. In Uganda church masses were split up into 8-10 church services per day only allowing smaller groups to enter at a time, so that attenders could sit with space between them. Markets were organized better etc. That was never done in Liberia – there was no close interaction between the Ugandan team and the Liberian health authorities. Had they contacted us we could have shared this kind of information – we felt they didn’t want our experience”.

The experienced Ebola expert lists his suggestions for future outbreaks, some of them are controversial he admits, but necessary he says:

1. Better protective gear should be provided. Protective suit should have oxygen and better ventilation so health workers can work for longer periods and not be interrupted by fatigue as often.
2. Transparent body bags for safe but (more) culturally appropriate funerals.
3. Cameras should be installed to observe management and for training of new staff. It also serves to minimize physical patient contact while maintaining emotional support.
4. Money should not be the sole criteria for attracting health workers: they should be carefully selected. Incompetent sloppy health workers put the other team members at a high risk.
5. Experienced Ebola management teams should always be called in and their experience should be collected and used after careful local adaptation. An international unit should secure that previous experience is made available to local response teams and authorities.
6. Church services should be organized to minimize physical contact. Public messages about greetings should be in place. Schools and markets should be re-organised to minimize contact.
7. Issues of salary should be dealt with promptly before they jeopardize safety and delay management.
8. Fleeing doctors and nurses and abandoned health facilities can be avoided by better training and constant supervision. The three weeks closure of the MSF hospital in Monrovia is likely to have delayed the response.
9. Morning briefing meetings should be held every day with all stakeholders, including bus services, market place managements, police, religious leaders and school leaders. Normal information systems are not that effective and many counter productive rumors can be dealt with at these meetings.
10. Public messages should be prioritized but it requires that health workers are well trained for emergencies.
11. This thing (Ebola) can happen anywhere – so prepare for the event, don’t wait for it to happen

A strong elephant

Tony observed huge differences in death rates between different hospitals in Monrovia. Every day these data would be published, but nobody seemed to react to them, Tony recalls: “We (the Ugandan team) had very low death rates because we had routines and good training, but the other hospitals did not perform as well”. Some health workers even became jealous and asked “why don’t the Ugandans contract Ebola, die and go home in a coffin?”

He was proud of the fact that it was their experience from Uganda, and meticulous routines that did the trick – not some kind of magic – and he didn’t bother about the wickedness of the remarks. “I am a strong willed man confident that Uganda routines will combat Ebola”, he concluded. When Tony finished his 4½ month assignment in Monrovia, Liberia, his Liberian colleagues gave him a walking stick with a handle in the shape of an elephant. You are strong as an elephant they told him. He had confronted mismanagement, fear, jealousy and he beat Ebola for the sixth time.

 

For contact to Tony Walther Onena:

For media and other accounts of the 2000 Ebola outbreak and its heavy toll on heroic health workers:

• New York Times: http://www.nytimes.com/library/magazine/home/20010218mag-ebola.html
• The Guardian: http://www.theguardian.com/g2/story/0,3604,416866,00.html
• Associate Express: http://www.ugandamission.net/health/news/ebola.html#01-1008
• Bulletin of the WH:O http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560656/pdf/11196502.pdf